Rubí Ley 95

Rubí

Accessible and practical for daily care

Rubí offers solid coverage, affordable copayments, and full access to the provider network.

Hospital of your choice

Eyeglasses
benefit

Optional life insurance

Coverage for major expenses

Summary of Benefits:

Click any category to see detailed copays and coverage.

Benefit / Service Category

Emergency Services

Immediate emergency care

Preferred Network / Other Benefits

Accident

$0

Illness

$30 Preferred Network
$75 Other Facilities

Hospitalization

Hospital stays and inpatient care

Total, including Mental Health

$0 Preferred Network
$250 Other Facilities

Partial Mental Health

$0 Preferred Network
$150 Other Facilities

Outpatient Services

Consultations and treatments without hospitalization

Primary Care Physician

$10

Specialist

$18

Sub-specialist

$20

Psychiatry

$18

Psychologist

$18

Chiropractic

$12 Copay Limited to 15 sessions per year. (Combined with physical therapies)

Nutritionist

$12 Copay, Limited to 12 visits per year

Laboratories and X-Rays

0% Preferred Network
50% Other Facilities

Specialized Studies

Diagnostic tests and medical studies

CT Scan

40% Preferred Network
50% Other Facilities

Ultrasounds

0% Preferred Network
50% Other Facilities

Stress Test, Electrocardiogram,
Neurological Studies

50%

MRI, MRA

50% Limited to 1 per contract year

Rehabilitation and Habilitation Services

Therapies and necessary medical equipment

Physical therapy

$7 Copay, limited to
15 sessions (Combined with chiropractic
manipulations)

Respiratory therapy

$7 Copay

Major Medical Expenses

Major medical care and specialized equipment

Durable medical equipment

A 20% coinsurance applies. Pre-authorization required.

Pharmacy

Covered prescription medications

Annual Benefit $750,
then 80% applies.

Bioequivalent Generic

Preferred Pharmacy $10
Non-Preferred Pharmacy $15

Preferred Brand

25% min $25 Preferred Pharmacy 30% min $30 Non-Preferred
Pharmacy

Non-Preferred Brand

50% min $50 Preferred Pharmacy 55% min $55 Non-Preferred
Pharmacy

Specialized Products

50%

Preventive Services

Preventive care and ongoing management

Preventive Services (Including Women's Services)

0%

Preventive Immunizations (Vaccines)

0% administration costs apply

Vision Services

Exams, lenses, and vision benefits

Eye Exam (Refraction)

Covered 100% of
contracted rates after a $10 copay

Frame and Prescription

Covered 1 pair per subscriber,
up to $150 per contract year.
Covered by reimbursement

Dental Coverage

Diagnosis, prevention, and dental treatments

Periodic Oral Exam

Covered every 6 months

Restorative

50%

Endodontics

50%

Temporary Restorations (Crowns)

50%

Oral Surgery

50%

Note: This is a summary of benefits. Consult your plan documents for complete information. Copayments and coinsurance are subject to the annual maximum limit.

Benefit / Service Category

Emergency Services

Immediate emergency care

Preferred Network / Other Benefits

Accident	$0
Illness	$30 Preferred Network $75 Other Benefits

Hospitalization

Hospital stays and inpatient care

Total, including Mental Health	$0 Preferred Network $250 Other Benefits
Partial Mental Health	$0 Preferred Network $150 Other Benefits

Hospitalization

Hospital stays and inpatient care

Total, including Mental Health	$0 Preferred Network $250 Other Benefits
Partial Mental Health	$0 Preferred Network $150 Other Benefits

Outpatient Services

Consultations and treatments without hospitalization

Primary Care Physician	$10
Specialist	$18
Sub-Specialist	$20
Psychiatrist	$18
Psychologist	$18
Chiropractor	$12 Copay, limited to 15 sessions per year. (Combined with physical therapies)
Nutritionist	$12 copay, up to 12 visits per contract
Laboratories and X-Rays	0% Preferred Network 50% Other Benefits

Specialized Studies

Diagnostic tests and medical studies

CT Scan	40% Preferred Network 50% Other Benefits
Ultrasounds	0% Preferred Network 50% Other Benefits
Stress Test, Electrocardiogram, Neurological Studies	50%
MRI, MRA	50% Limited to 1 per contract year

Rehabilitation and Habilitation Services

Therapies and necessary medical equipment

Physical Therapy	$7 Copay, limited to 15 sessions (Combined with chiropractic manipulations)
Respiratory Therapy	$7 Copay

Major Medical Expenses

Major Medical Care and Specialized Equipment

Durable medical equipment

20% coinsurance applies. Pre-authorization required

Pharmacy

Covered prescription medications

	Annual Benefit $750, then 80% applies.
Generic Bioequivalent	Preferred Pharmacy $10 Non-Preferred Pharmacy $15
Preferred Brand	25% min $25 Preferred Pharmacy 30% min $30 Non-Preferred Pharmacy
Non-Preferred Brand	50% min $50 Preferred Pharmacy 55% min $55 Non-Preferred Pharmacy
Specialized Products	50%

Preventive Services

Preventive care and ongoing management

Preventive Services (Including Women's Services)	0%
Preventive Immunizations (Vaccines)	0% administration costs apply

Vision Services

Exams, lenses, and vision benefits

Eye Exam (Refraction)	Covered 100% of contracted rates after a $10 copay
Frame and Prescription	Covered 1 pair per subscriber, up to $150 per contract year. Covered by reimbursement.

Dental Coverage

Diagnosis, prevention, and dental treatments

Periodic Oral Exam	Covered every 6 months
Restaurative	50%
Endodontics	50%
Temporary Restorations (Crowns)	50%
Oral Surgery	50%

Note: This is a summary of benefits. Consult your plan documents for complete information. Copayments and coinsurance are subject to the annual maximum limit.

Rubí

Summary of Benefits:

Benefit / Service Category

Accident

$0

Illness

$30 Preferred Network$75 Other Facilities

Total, including Mental Health

$0 Preferred Network$250 Other Facilities

Partial Mental Health

$0 Preferred Network$150 Other Facilities

Primary Care Physician

$10

Specialist

$18

Sub-specialist

$20

Psychiatry

$18

Psychologist

$18

Chiropractic

$12 Copay Limited to 15 sessions per year. (Combined with physical therapies)

Nutritionist

$12 Copay, Limited to 12 visits per year

Laboratories and X-Rays

0% Preferred Network50% Other Facilities

CT Scan

40% Preferred Network50% Other Facilities

Ultrasounds

0% Preferred Network50% Other Facilities

Stress Test, Electrocardiogram,Neurological Studies

50%

MRI, MRA

50% Limited to 1 per contract year

Physical therapy

$7 Copay, limited to15 sessions (Combined with chiropractic manipulations)

Respiratory therapy

$7 Copay

Durable medical equipment

A 20% coinsurance applies. Pre-authorization required.

Annual Benefit $750,then 80% applies.

Bioequivalent Generic

Preferred Pharmacy $10Non-Preferred Pharmacy $15

Preferred Brand

25% min $25 Preferred Pharmacy 30% min $30 Non-PreferredPharmacy

Non-Preferred Brand

50% min $50 Preferred Pharmacy 55% min $55 Non-PreferredPharmacy

Specialized Products

50%

Preventive Services (Including Women's Services)

0%

Preventive Immunizations (Vaccines)

0% administration costs apply

Eye Exam (Refraction)

Covered 100% ofcontracted rates after a $10 copay

Frame and Prescription

Covered 1 pair per subscriber,up to $150 per contract year.Covered by reimbursement

Periodic Oral Exam

Covered every 6 months

Restorative

50%

Endodontics

50%

Temporary Restorations (Crowns)

50%

Oral Surgery

50%

Benefit / Service Category

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$30 Preferred Network
$75 Other Facilities

$0 Preferred Network
$250 Other Facilities

$0 Preferred Network
$150 Other Facilities

0% Preferred Network
50% Other Facilities

40% Preferred Network
50% Other Facilities

0% Preferred Network
50% Other Facilities

Stress Test, Electrocardiogram,
Neurological Studies

$7 Copay, limited to
15 sessions (Combined with chiropractic
manipulations)

Annual Benefit $750,
then 80% applies.

Preferred Pharmacy $10
Non-Preferred Pharmacy $15

25% min $25 Preferred Pharmacy 30% min $30 Non-Preferred
Pharmacy

50% min $50 Preferred Pharmacy 55% min $55 Non-Preferred
Pharmacy

Covered 100% of
contracted rates after a $10 copay

Covered 1 pair per subscriber,
up to $150 per contract year.
Covered by reimbursement